IPSA - International Partners for Study Abroad

Spanish Language School in Manta, Ecuador.

Online Secure Application Form.


Part A. Personal data:


Mr/Mrs/Ms/Miss


First Name:


Last Name:


Home Address:

Street Address:


City:


State/Province:


ZIP (Postal) Code:


Country:


Day Telephone Number:


Evening Telephone Number:


E-mail:


Fax: [optional]


Date of Birth: month day year            Male Female

Place of Birth (country, city):   

Citizenship (country):

Passport Number:


Nationality:


Your native language:


Other languages, if any:


I am currently: a college/university freshman sophomore junior senior
Graduate Student High School Senior Interested Adult Professional

If you are a graduate or undergraduate student, please provide the following information:

Current college/university/graduate school:

My major field of study:       GPA

If you are a professional, please specify your profession and company:

Profession:

Please enter the address of your college, university or company:






Emergency Contact:


Name:


Relationship:


Telephone:


Address:






Part B. Program data.

Which course would you like to study?

Individual Intensive Spanish Language Course:

      Please select number of private lessons per day:
       4        5        6        7


Medical Spanish Program

Closed Group Spanish Language Course:

      Please select number of group lessons per week:
       15        20        25


Manta Activo:

      Please select number of private lessons per day:
       6     7


Eco Volunteer Program

      Please select number of weeks:
       6 weeks     8 weeks


Spanish plus Surfing

Spanish plus Kiteboarding



When would you like to start your course:

Day: Month: Year:

For how many weeks you want to register:

Number of weeks:


Comments:

What is your present level of Spanish?

Beginner
Elementary
Intermediate
Upper-intermediate
Advanced

Which areas would you most like to improve:

Speaking
Understanding
Listening
Reading
Writing
Vocabulary
Grammar
Other:





Part C. Accomodations.

Do you require Accommodation? yes no

If yes, please select the accommodation type:

Host Family
Students' apartment

If you require accommodations, please also fill in below:
Are you a smoker ? yes
no
If you have a special diet, please specify:
If you have allergies, please specify:
If you have other requirements, please specify:


Flight arrival information:







Part C. Payment of Fees:

Please note that your application will be considered only when your payment of the non-refundable Application Fee of US $100.00 and the tuition deposit of $200.00 has been received.

Please note that you may apply online only if you pay an application fee and the tuition deposit by credit card.

If you are going to pay an application fee by cashiers check, money order or by wire transfer, please print out a monospaced Application Form from your browser and send it with your payment by mail.


Payment by Credit Card

We accept only VISA and MasterCard. In this Form, we utilize the Secure Socket Layer (SSL) authentication and RC4 128 bit encryption technology. SSL encryption protects information being transmitted across the internet to our processing center.

Please charge the application fee of US $100.00 and the tuition deposit of $200.00 to my credit card provided below

Please charge the application fee and the full payment to my credit card provided below.

Even if you select a "full payment" option, we will charge only the application fee and the deposit at the time of accepting your application and will process the payment of the balance to your credit card after registering you for the course. Please also note that if you would prefer to pay the balance by credit card, a 4.5% convenience payment processing service fee will be included in the invoice. There are no any additional charges on your payment of the application fee and the tuition deposit by credit card.


To process your payment using Visa or MasterCard, please fill in the fields below with the requested information EXACTLY as it appears on your monthly bankcard statement.

Please select credit card:


Cardnumber:


Expiration Month:


Expiration Year:


Card Verification Value:
The last three digits on the back of your credit card after the credit card number. This value protects you from online fraud by verifying that you are in possession of the card you are attempting to use.


Cardholder Billing Information:

Cardholder Name:


Street Address:


City:


State:


Zip Code:



Please double-check the above credit card information.





Part D. Autobiographical Essay.

Please write a brief essay. This essay must contain a short story of your life and experience, and reasons why you wish to study abroad.






Part E. Agreement and release.

By submitting this Application, I certify the above information is complete and correct. I understand that my misrepresentation may result in my expulsion from the program. I acknowledge that the terms and conditions appearing on this site constitute part of my agreement with IPSA and study abroad program host (university, college, language school, or other institution and/or organization), including sections concerning responsibility, health, refunds, changes in dates, accommodations, courses and billing of the selected options. I assume all risks and responsibilities and discharge IPSA and the study abroad program host and all their officers, agents and employees from and against any and all claims of damage to personal property or personal injury which may result from my enrollment and participation in the study abroad program host courses, excursions, and/or on and off-campus activities. I have read the Agreement and agree to follow all IPSA and study abroad host procedures. This Agreement will be effective when my application is accepted by IPSA and shall be governed by the laws of the State of Arizona, USA.

Yes, I agree. I don't agree


Please click on the button to submit the Application: